ATI RN
ATI Vital Signs Assessment Questions
Question 1 of 5
The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is correct?
Correct Answer: B
Rationale: The correct technique when using an otoscope to assess the nasal cavity is to avoid touching the nasal septum with the speculum. This is important because the nasal septum is a sensitive area that can be easily irritated or damaged. By avoiding contact with the septum, the nurse can prevent discomfort or potential injury to the patient. Choice A is incorrect because inserting the speculum 3 cm into the vestibule is unnecessary and may cause discomfort to the patient. Choice C is incorrect as displacing the nose can distort the anatomy and make it difficult to assess the nasal cavity accurately. Choice D is incorrect as keeping the speculum tip medial to avoid touching the floor of the nares is not a standard technique and may not provide an optimal view of the nasal cavity.
Question 2 of 5
During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?
Correct Answer: A
Rationale: The correct answer is A: When the bronchial tree is obstructed. Decreased breath sounds are expected in situations where airflow is obstructed, leading to diminished sound transmission. When there is an obstruction in the bronchial tree, such as in asthma or bronchitis, breath sounds become decreased due to the restricted airflow. The other choices are incorrect because: B: When adventitious sounds are present - Adventitious sounds like crackles or wheezes indicate abnormal lung sounds but do not necessarily result in decreased breath sounds. C: In conjunction with whispered pectoriloquy - Whispered pectoriloquy is a finding where whispering is heard clearly through the stethoscope, indicating lung consolidation rather than decreased breath sounds. D: In conditions of consolidation, such as pneumonia - Consolidation leads to increased breath sounds due to the denser lung tissue, not decreased breath sounds.
Question 3 of 5
If a patient reports a recent breast infection, then the nurse should expect to find _____ node enlargement.
Correct Answer: B
Rationale: The correct answer is B: Ipsilateral axillary. When a patient reports a breast infection, it is likely localized to one breast. The lymphatic drainage from the breast primarily flows to the ipsilateral axillary lymph nodes. Therefore, the nurse should expect to find enlargement in the ipsilateral axillary nodes as they are the first line of defense in filtering out any infection or inflammation from the affected breast. Choices A, C, and D are incorrect because nonspecific node enlargement would not be specific to a breast infection, contralateral axillary nodes would not be affected by a unilateral breast infection, and inguinal and cervical nodes are not typically involved in breast infections.
Question 4 of 5
During the physical examination, the nurse notices that a female patient has an inverted left nipple. Which statement regarding this is most accurate?
Correct Answer: C
Rationale: Rationale: C is correct because determining if the inversion is a recent change is crucial to assess for potential underlying causes like breast cancer. A: Incorrect because nipple inversion can be unilateral. B: Incorrect, unilateral inversion doesn't always indicate a serious condition. D: Incorrect, nipple inversion alone warrants further investigation regardless of a palpable mass.
Question 5 of 5
The mother of a 3-month-old infant states that her baby has not been gaining weight. With further questioning, the nurse finds that the infant falls asleep after nursing and wakes up after a short time, hungry again. What other information would the nurse want to have?
Correct Answer: D
Rationale: The correct answer is D: Presence of dyspnea or diaphoresis when sucking. This information is crucial as it could indicate a medical issue such as a respiratory problem or heart condition affecting the baby's ability to feed properly, leading to poor weight gain. Dyspnea (difficulty breathing) and diaphoresis (excessive sweating) during sucking are red flags that require immediate medical attention. A: The infant's sleeping position is important for preventing Sudden Infant Death Syndrome (SIDS) but not directly related to the feeding issue. B: Sibling history of eating disorders may not be relevant to the current infant's feeding difficulties. C: Amount of background noise when eating is unlikely to be the primary factor affecting the infant's weight gain issue.